Database analysis comparing incidence and complication rates between inpatient and outpatient laminotomies for lumbar disc herniation.

Background: Lumbar disc herniation (LDH) is a common condition that can be characterized with disabling pain. While most patients recover without surgery, some still require operative intervention. The epidemiology and trends of laminotomy for LDH have not been recently studied, and current practice patterns might be different from historical norms. This study aimed to investigate the trends of inpatient and outpatient laminotomies for LDH and compare complication rates between these two sites of service. Methods: A large, national database was utilized to identify patients > 8 years old who underwent a laminotomy for LDH between 2009 and 2019. Two cohorts were created based on site of surgery: inpatient versus outpatient. The outpatient cohort was defined as patients who had a length of stay less than 1 day without any associated hospitalization. Epidemiologic analyses for these cohorts were performed by demographics. Patients in both groups were then 1:1 propensity-score matched based on age, sex, insurance type, geographic region, and comorbidities. Ninety-day postoperative complications were compared between cohorts utilizing multivariate logistic regressions. Results: The average incidence of laminotomy for LDH was 13.0 per 10,000 persons-years. Although the national trend in incidence had not changed from 2009 to 2019, the proportion of outpatient laminotomies significantly increased in this time period (p=.02). Outpatient laminotomies were more common among younger and healthier patients. Patients with inpatient laminotomies had significantly higher rates of surgical site infections (odds ratio [OR] 1.61, p<.001), venous thromboembolism (VTE) (OR 1.96, p<.001), hematoma (OR 1.71, p<.001), urinary tract infections (OR 1.41, p<.001), and acute kidney injuries (OR 1.75, p=.001), even when controlling for selected confounders. Conclusions: Our study demonstrated an increasing trend in the performance of laminotomy for LDH toward the outpatient setting. Even when controlling for certain confounders, patients requiring inpatient procedures had higher rates of postoperative complications. This study highlights the importance of carefully evaluating the advantages and disadvantages of performing these procedures in an outpatient versus inpatient setting.

Case report: Magnetic resonance imaging features with postoperative improvement of atypical cervical glioma characterized by predominant extramedullary distribution in a dog.

Introduction: Intramedullary cord tumors present diagnostic and therapeutic challenges. Furthermore, spinal cord tumors can move across compartments, making antemortem diagnosis difficult, even with advanced imaging. This report presents a rare case of a cranial cervical spinal glioma, confirmed by surgical histopathology, with postoperative improvement in a dog. Case description: A 9-year-old female Maltese dog presented with kyphotic posture, progressive left hemiparesis, and decreased appetite. Neurological examination revealed neck pain and decreased proprioception in the left limbs along with intact deep pain perception. Two days later, the patient developed non-ambulatory tetraparesis. Magnetic resonance imaging (MRI) revealed an ovoid, well-defined mass with homogeneously marked contrast enhancement in the second cervical spinal cord that severely compressed the spinal cord. This mass was heterogeneously hyperintense on T2-weighted images and iso-to-hypointense on T1-weighted images, showing an appearance resembling the "golf-tee" and "dural tail" signs. The MRI findings suggested an intradural extramedullary tumor. Intraoperatively, a well-demarcated mass which was locally adherent to the spinal meninges was removed. Both histopathological and genomic tumor tests were indicative of a glioma. Approximately 2 weeks postoperatively, the patient's neurological signs returned to normal. Conclusion: This case report describes an atypical cervical glioma with complicated MR characteristics in a dog, where MRI helped guide surgical intervention.

Clinical outcome after surgical management of spontaneous spinal epidural hematoma.

PURPOSE: Spontaneous spinal epidural hematoma (SSEH) is a rare pathology characterized by a hemorrhage in the spinal epidural space without prior surgical or interventional procedure. Recent literature reported contradictory findings regarding the clinical, radiological and surgical factors determining the outcome, hence the objective of this retrospective analysis was to re-assess these outcome-determining factors. METHODS: Patients surgically treated for SSEH at our institution from 2010 - 2022 were screened and retrospectively assessed regarding management including the time-to-treatment, the pre-and post-treatment clinical status, the radiological findings as well as other patient-specific parameters. The outcome was assessed using the modified McCormick Scale. Statistical analyses included binary logistic regression and Fisher's exact test. RESULTS: In total, 26 patients (17 men [65%], 9 women [35%], median age 70 years [interquartile range 26.5]) were included for analysis. The SSEHs were located cervically in 31%, cervicothoracically in 42% and thoracically in 27%. Twenty-four patients (92%) improved after surgery. Fifteen patients (58%) had a postoperative modified McCormick Scale grade of I (no residual symptoms) and 8 patients (31%) had a grade of II (mild symptoms). Only 3 (12%) patients remained with a modified McCormick Scale grade of IV or V (severe motor deficits / paraplegic). Neither time-to-treatment, craniocaudal hematoma expansion, axial hematoma occupation of the spinal canal, anticoagulation or antiplatelet drugs, nor the preoperative clinical status were significantly associated with the patients' outcomes. CONCLUSION: Early surgical evacuation of SSEH generally leads to favorable clinical outcomes. Surgical hematoma evacuation should be indicated in all patients with symptomatic SSEH.

Clinical Outcomes Following Decompression of Central Canal and Lateral Recess Simultaneous Stenosis, with a Focus on Multilevel Stenosis: A Randomized Comparison of Microscopic Bilateral Laminotomy versus Total Laminectomy with Posterior Spinal Fusion.

BACKGROUND: In patients with simultaneous lumbar central spinal stenosis (LCSS) and lateral recess stenosis (LRS) at multiple levels, spinal decompression using microscopic bilateral laminotomy was compared to total laminectomy plus medial facetectomy and fusion (LF). METHODS: From 2017 to 2022, this trial was performed to examine 96 patients with concomitant LCS and LRS at multilevel. Of the 96 patients, 48 were allocated to the following groups: LF (group I) or microscopic bilateral laminotomy (group II). However, 76 patients completed the study. We compared the outcomes in these 2 groups. RESULTS: Microscopic bilateral laminotomy was superior in most outcome measures. Delta-visual analog scale leg pain in group II was significantly greater than in group I (mean-group I: 4.368 vs. group II: 5.368, P value = 0.001). Complication and revision rates were lower in the microscopic bilateral laminotomy than in group I, except for incidental durotomy occurrence (group II: 31.58% -group I: 7.89%, P value = 0.0190). The rate of revision surgery for group I compared with group II was 44.74% versus 13.16% (P value = 0.0047), indicating the superiority of laminotomy over LF. The mean length of hospital stay was 3.551 ± 0.6349 in group II versus 6.774 ± 1.197 in group I (P value <0.0001). Also, blood loss during surgery was significantly lower in group II (P value <0.0001). CONCLUSIONS: The findings indicate that microscopic bilateral laminotomy provides favorable clinical and radiological outcomes for individuals experiencing multilevel lumbar central canal and LRS. However, a higher frequency of durotomy may occur during microsurgical procedures.

Long-term efficacy of microendoscopic laminotomy for lumbar spinal stenosis in advanced degenerative spondylolisthesis with or without dynamic spinal instability: a propensity score-matching analysis.

OBJECTIVE: In this study, the authors aimed to determine the mid- to long-term outcomes of microendoscopic laminotomy (MEL) for lumbar spinal stenosis (LSS) with degenerative spondylolisthesis (DS) and identify preoperative predictors of poor mid- to long-term outcomes. METHODS: The authors retrospectively reviewed the medical records of 274 patients who underwent spinal MEL for symptomatic LSS. The minimum postoperative follow-up duration was 5 years. Patients were classified into two groups according to DS: those with DS (the DS+ group) and those without DS (the DS- group). The patients were subjected to propensity score matching based on sex, age, BMI, surgical segments, and preoperative leg pain visual analog scale scores. Clinical outcomes were evaluated 1 year and > 5 years after surgery. RESULTS: Surgical outcomes of MEL for LSS were not significantly different between the DS+ and DS- groups at the final follow-up (mean 7.8 years) in terms of Oswestry Disability Index (p = 0.498), satisfaction (p = 0.913), and reoperation rate (p = 0.154). In the multivariate analysis, female sex (standard ß -0.260), patients with slip angle > 5° in the forward bending position (standard ß -0.313), and those with dynamic progression of Meyerding grade (standard ß -0.325) were at a high risk of poor long-term outcomes. CONCLUSIONS: MEL may have good long-term results in patients with DS without dynamic instability. Women with dynamic instability may require additional fusion surgery in approximately 25% of cases for a period of ≥ 5 years.

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report.

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

Full endoscopic laminotomy decompression versus anterior cervical discectomy and fusion for the treatment of single-segment cervical spinal stenosis: a retrospective, propensity score-matched study.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is the standard procedure for the treatment of cervical spinal stenosis (CSS), but complications such as adjacent segment degeneration can seriously affect the long-term efficacy. Currently, posterior endoscopic surgery has been increasingly used in the clinical treatment of CSS. The aim of this study was to compare the clinical outcomes of single-segment CSS patients who underwent full endoscopic laminotomy decompression or ACDF. METHODS: 138 CSS patients who met the inclusion criteria from June 2018 to August 2020 were retrospectively analyzed and divided into endoscopic and ACDF groups. The propensity score matching (PSM) method was used to adjust the imbalanced confounding variables between the groups. Then, perioperative data were recorded and clinical outcomes were compared, including functional scores and imaging data. Functional scores included Visual Analog Scale of Arms (A-VAS) and Neck pain (N-VAS), Japanese Orthopedic Association score (JOA), Neck Disability Index (NDI), and imaging data included Disc Height Index (DHI), Cervical range of motion (ROM), and Ratio of grey scale (RVG). RESULTS: After PSM, 84 patients were included in the study and followed for 24-30 months. The endoscopic group was significantly superior to the ACDF group in terms of operative time, intraoperative blood loss, incision length, and hospital stay (P < 0.001). Postoperative N-VAS, A-VAS, JOA, and NDI were significantly improved in both groups compared with the preoperative period (P < 0.001), and the endoscopic group showed better improvement at 7 days postoperatively (P < 0.05). The ROM changes of adjacent segments were significantly larger in the ACDF group at 12 months postoperatively and at the last follow-up (P < 0.05). The RVG of adjacent segments showed a decreasing trend, and the decrease was more marked in the ACDF group at last follow-up (P < 0.05). According to the modified MacNab criteria, the excellent and good rates in the endoscopic group and ACDF group were 90.48% and 88.10%, respectively, with no statistically significant difference (P > 0.05). CONCLUSION: Full endoscopic laminotomy decompression is demonstrated to be an efficacious alternative technique to traditional ACDF for the treatment of single-segment CSS, with the advantages of less trauma, faster recovery, and less impact on cervical spine kinematics and adjacent segmental degeneration.

[Comparison of effectiveness between unilateral biportal endoscopic and uniportal interlaminar endoscopic decompression in the treatment of lumbar spinal stenosis].

Objective: To compare the effectiveness between unilateral laminotomy and bilateral decompression (ULBD) with unilateral biportal endoscopy (UBE) and uniportal interlaminar endoscopy (UIE) in the treatment of lumbar spinal stenosis. Methods: A clinical data of 52 patients with lumbar spinal stenosis, who met the selection criteria and treated with ULBD between March 2021 and November 2022, was retrospectively analyzed. The patients were allocated into UBE group (23 cases) and UIE group (29 cases) according to the surgical methods. There was no significant difference ( P>0.05) in age, gender, body mass index, surgical segment, type of lumbar stenosis, and preoperative visual analogue scale (VAS) score of low back pain, VAS score of leg pain, Oswestry disability index (ODI), disc height, and dural sac area between the two groups. Perioperative indexes (incision length, operation time, hospital stay, and surgical complications), clinical indicators (VAS score of low back pain, VAS score of leg pain, and ODI before operation and at 3 days, 1 month, 6 months, and 12 months after operation), and imaging indicators (disc height and dural sac area before operation and at 1, 12 months after operation, and dural sac expansion area) were recorded and compared between the two group. Results: All operations in both groups were successfully completed. Compared with the UIE group, the UBE group had shorter operation time and longer incision length, with significant differences ( P<0.05). But there was no significant difference in hospital stay and incidence of complications between the two groups ( P>0.05). All patients were followed up 12-20 months (mean, 14 months). The VAS scores of low back pain and leg pain and ODI after operation significantly improved when compared with preoperative values ( P<0.05), and there was no significant difference in the above indicators between different time points after operation ( P>0.05). There was no significant difference between the two groups at different time points ( P>0.05). Imaging examination showed that there was no significant difference in disc height between the two groups at different time points after operation ( P>0.05). However, the dural sac area and dural sac expansion area were significantly larger in the UBE group than in the UIE group ( P<0.05). Conclusion: ULBD with UBE and UIE can achieve satisfactory effectiveness in the treatment of lumbar spinal stenosis. But the former has more thorough decompression and better dural sac expansion than the latter.

The Influence of Spinous Process Union on Clinical Outcomes After Spinous Process Osteotomy for Lumbar Spinal Stenosis After 2 Years: A Secondary Analysis From the NORDSTEN-Study.

BACKGROUND: Lumbar spinal stenosis is a prevalent and increasingly important cause of low back pain, leg pain, and walking impairment. Minimally invasive decompressive techniques such as spinous process (SP) osteotomy have become more common in recent years. The main aim of this study was to investigate the proportion of complete SP union and whether complete radiological healing after the osteotomy is associated with superior clinical outcome after 2 years. METHODS: In this retrospective cohort study, 149 patients were included from the Spinal Stenosis Trial, a part of the NORwegian Degenerative spondylolisthesis and spinal STENosis study. Computed tomography imaging was performed 2 years postoperatively. The number of osteotomies and the number of SP unions were recorded. Patients were divided into groups based on the degree of union: nonunion, partial union, and complete union. Rate of success (>30% improvement in Oswestry Disability Index [ODI]) and mean change in ODI were the primary outcome measures. We compared the differences between baseline and follow-up between the Degree of Union groups. RESULTS: The study included 102 of 149 eligible patients. Ten patients (9.8%) were classified as having nonunion, 15 (14.7%) as having partial union, and 77 (75.5%) as having complete union. Of the 155 osteotomies, there were 122 classified as union (77%). The success rate was 74%, with no influence of SP union. The mean change in the ODI was -20.1 (95% CI -37.0, 14.2) with no influence of SP union. CONCLUSIONS: We found no influence of SP union, classified by computed tomography, on clinical outcome 2 years after SP osteotomy in patients with lumbar spinal stenosis. CLINICAL RELEVANCE: Supplying useful information about SPO to assist surgeons in the choice of decompressive technique.

Minimally Invasive Resection of a Foraminal Lumbar Root Schwannoma.

Background and Importance: This video article reports a rare case of a right L5/S1 foraminal root schwannoma that presents the natural course of the disease, imaging findings, treatment protocol, operative procedure, and highlights some of the possible surgical complications. Clinical Presentation: Magnetic resonance imaging (MRI) revealed an intradural, extramedullary, well-enhanced mass at the right L5/S1 level. The operative procedure involved a right minimal L5/S1 laminotomy/foraminotomy posteriorly to open the right L5 root. The facet joints were preserved to prevent spinal instability. The tumor was located along the root after opening the right L5/S1 foramen. Intraoperative electromyography (IOM) was conducted to detect any nerve injury in the patient. After opening the dura, the tumor was carefully separated from the normal root nerve under IOM monitoring. The mass was removed piece-by-piece using mini-forceps. Conclusion: Histopathological examination confirmed the diagnosis of a schwannoma. The patient recovered without incident after surgery with minimal soreness and numbness in the right leg.

Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation.

OBJECTIVES: Placement of a standard paddle lead for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a "skip" laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified. MATERIALS AND METHODS: Participants who underwent SCS paddle placement at Albany Medical Center between 2016 and 2017 were identified. Operative reports were reviewed to identify the paddle type, level of initial laminotomy, target level, and skip laminotomy level. Preoperative thoracic magnetic resonance images (MRIs) were reviewed, and spinal canal diameter, interpedicular distance, and dorsal cerebral spinal fluid thickness were measured for each participant when available. RESULTS: A total of 106 participants underwent thoracic SCS placement. Of these, 97 had thoracic MRIs available for review. Thirty-eight participants required a skip laminotomy for placement of the paddle compared with 68 participants who did not. There was no significant difference in demographic features including age, sex, body mass index, and surgical history. Univariate analyses that suggested trends were selected for further analysis using binary logistic regression. Level of initial laminotomy (odds ratio [OR] = 1.51, p = 0.028), spinal canal diameter (OR = 0.71, p = 0.015), and dorsal cerebrospinal fluid thickness (OR = 0.61, p = 0.011) were correlated with skip laminotomy. Target level (OR = 1.27, p = 0.138) and time from trial (1.01, p = 0.117) suggested potential association. The multivariate regression was statistically significant, X2(10) = 28.02, p = 0.002. The model explained 38.3% of the variance (Nagelkerke R2) and predicted skip laminectomy correctly in 73.3% of cases. However, for the multivariate regression, only a decrease in spinal canal diameter (OR = 0.59, p = 0.041) was associated with a greater odds of skip laminotomy. CONCLUSIONS: This study aims to characterize the patient and radiographic factors that may predict the need to perform a skip laminotomy during the initial placement of SCS paddles. Here, we show that radiographic and anatomic variables, primarily spinal canal diameter, play an important role in predicting the need for a skip laminotomy. Furthermore, we suggest that target level for placement and level of initial laminotomy also may contribute. Further investigation of the predictive factors for performing a skip laminotomy would help optimize surgical planning and preoperative patient selection and counseling.

Comparison of biportal endoscopic technique and uniportal endoscopic technique in Unilateral Laminectomy for Bilateral Decomprssion (ULBD) for lumbar spinal stenosis.

OBJECTIVE: Unilateral laminotomy for bilateral decompression (ULBD) has been adopted widely to treat lumbar spinal stenosis (LSS). The objective of the study is to investigate clinical and radiological outcomes of the biportal endoscopic ULBD (BE-ULBD) and uniportal endoscopic ULBD (UE-ULBD). METHODS: We collected retrospectively 65 patients' data who met the inclusion criteria (July 2019-June 2021). 33 patients underwent BE-ULBD surgery, and 32 patients underwent the UE-ULBD surgery, and were followed up for at least 1 year. The following preoperative and postoperative outcomes were compared between groups: the visual analog scale (VAS) for pain, the Oswestry disability index (ODI) for nerve function, and modified Macnab criteria for satisfaction, the cross-sectional area of the dural sac (DSCSA), the mean angle of facetectomy. RESULTS: Age, BMI, gender, levels of involvement and duration of symptoms were not significantly different at baseline in this study. Clinical data showed that postoperative ODI, VAS scores and Modified Macnab Criteria were not statistically different between the two groups. The BE-ULBD group had a shorter operation time than the UE-ULBD group (P < 0.001). Patients in the BE-ULBD group had a larger postoperative expansion of DSCSA expansion postoperatively (85.58 ± 3.16 mm2 VS 71.43 ± 3.35 mm2, P < 0.001) and a larger contralateral facetectomy angle (63.95 ± 3.34° vs 57.80 ± 3.43°, P < 0.001) compared with patients in the UE-ULBD group. There were no statistical differences in the incidence of postoperative complications between the two groups. CONCLUSION: Both the BE-ULBD and the UE-ULBD yielded clinical improvement in terms of pain and stenosis symptoms. The BE-ULBD technique has the advantages of the shorter operation time, larger DSCSA expansion and larger contralateral facetectomy angle.

Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation.

BACKGROUND: Unilateral laminotomy for bilateral decompression (ULBD) is a MIS surgical technique that offers safe and effective decompression of lumbar spinal stenosis (LSS) with a long-term resolution of symptoms. Advantages over conventional open laminectomy include reduced expected blood loss, muscle damage, mechanical instability, and less postoperative pain. The slalom technique combined with navigation is used in multi-segmental LSS to improve the workflow and effectiveness of the procedure. METHODS: We outline ten technical steps to achieve a slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation. In a retrospective case series, we included patients with multi-segmental LSS operated in our institution using the sULBD between 2020 and 2022. The primary outcome was a reduction in pain measured by Visual Analogue Scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI). RESULTS: In our case series (N = 7), all patients reported resolution of initial symptoms on an average follow-up of 20.71 ± 9 months. The average operative time and length of hospital stay were 196.14 min and 1.67 days, respectively. On average, VAS (back pain) was 4.71 pre-operatively and 1.50 on long-term follow-up of an average of 19.05 months. VAS (leg pain) decreased from 4.33 to 1.21. ODI was reported as 33% pre-operatively and 12% on long-term follow-up. CONCLUSION: The sULBD with navigation is a safe and effective MIS surgical procedure and achieves the resolution of symptoms in patients presenting with multi-segmental LSS. Herein, we demonstrate the ten key steps required to perform the sULBD technique. Compared to the standard sULBD technique, the incorporation of navigation provides anatomic localization without exposure to radiation to staff for a higher safety profile along with a fast and efficient workflow.

Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications.

BACKGROUND: Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently. AIM: To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature. METHODS: On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles. RESULTS: A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%. CONCLUSION: Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques.

Effect of graded posterior element and ligament removal on annulus stress and segmental stability in lumbar spine stenosis: a finite element analysis study.

The study aimed to investigate the impact of posterior element and ligament removal on the maximum von Mises stress, and maximum shear stress of the eight-layer annulus for treating stenosis at the L3-L4 and L4-L5 levels in the lumbar spine. Previous studies have indicated that laminectomy alone can result in segmental instability unless fusion is performed. However, no direct correlations have been established regarding the impact of posterior and ligament removal. To address this gap, four models were developed: Model 1 represented the intact L2-L5 model, while model 2 involved a unilateral laminotomy involving the removal of a section of the L4 inferior lamina and 50% of the ligament flavum between L4 and L5. Model 3 consisted of a complete laminectomy, which included the removal of the spinous process and lamina of L4, as well as the relevant connecting ligaments between L3-L4 and L4-L5 (ligament flavum, interspinous ligament, supraspinous ligament). In the fourth model, a complete laminectomy with 50% facetectomy was conducted. This involved the same removals as in model 3, along with a 50% removal of the inferior/superior facets of L4 and a 50% removal of the facet capsular ligaments between L3-L4 and L4-L5. The results indicated a significant change in the range of motion (ROM) at the L3-L4 and L4-L5 levels during flexion and torque situations, but no significant change during extension and bending simulation. The ROM increased by 10% from model 1 and 2 to model 3, and by 20% to model 4 during flexion simulation. The maximum shear stress and maximum von-Mises stress of the annulus and nucleus at the L3-L4 levels exhibited the greatest increase during flexion. In all eight layers of the annulus, there was an observed increase in both the maximum shear stress and maximum von-Mises stress from model 1&2 to model 3 and model 4, with the highest rate of increase noted in layers 7&8. These findings suggest that graded posterior element and ligament removal have a notable impact on stress distribution and range of motion in the lumbar spine, particularly during flexion.

Consecutive Case Series of Uniportal Full-endoscopic Unilateral Laminotomy for Bilateral Decompression in Lumbar Spinal Stenosis: Relationship between Decompression Range and Functional Outcomes.

OBJECTIVE: Uniportal full-endoscopic unilateral laminotomy for bilateral decompression (UFE-ULBD) has been used to treat lumbar spinal stenosis (LSS) with satisfactory outcomes. However, a limited number of studies have investigated the relationship between decompression range and clinical outcomes. This study aimed to investigate the efficacy of UFE-ULBD for single-segment LSS and to explore the relationship between the decompression range and functional outcomes. METHODS: Single-segment LSS patients who had undergone UFE-ULBD using an interlaminar approach between November 2021 and February 2023 were retrospectively analyzed. Patient demographics, visual analogue scale (VAS) scores for leg and back pain, Oswestry disability index (ODI) scores, modified MacNab grades, and radiological outcomes, including the decompression ratio of the disc-flava ligament space and osseous lateral recess, the enlargement ratio of superior articular process interval, lamina interval dural sac cross-sectional area (DSCA), were collected. The independent sample t-tests, paired sample t-tests, chi-square tests, Fisher's exact tests, and Pearson's and Spearman's correlation analyses were used. RESULTS: Forty patients (23 males, and 17 females) were retrospectively enrolled in this study. The mean follow-up period was 12 months. At the last follow-up, VAS scores for leg pain and back pain decreased from 6.0 ± 0.8 to 1.0 ± 1.9 (p < 0.001), and from 6.0 ± 0.8 to 1.2 ± 1.8 (p < 0.001) respectively; ODI score decreased from 71.7 ± 6.2 to 24.3 ± 21.3 (p < 0.001). According to the modified MacNab criteria, the results were excellent in 28 (70%), good in 5 (12.5%), fair in 6 (15%), and poor in 1 (2.5%), with an excellent-good rate of 82.5%. The postoperative DSCA enlarged from 57.69 ± 21.86 to 150.75 ± 39.33 mm2 (p < 0.001), with an enlargement ratio of 189.43 ± 107.83%. No difference in clinical or radiological parameters was detected between patients with excellent, good, fair, or poor outcomes based on the modified MacNab criteria. CONCLUSION: UFE-ULBD can provide satisfactory clinical and radiological outcomes in single-segment LSS patients. With sufficient exposure to the dural sac boundary, the functional outcome was not related to the radiological decompression range in LSS patients who had undergone UFE-ULBD.

A case of neurosurgical treatment of thoracic dorsal arachnoid web.

Background: Dorsal arachnoid webs constitute abnormal formations of arachnoid that tend to occur in the upper thoracic spine and can lead to spinal cord displacement. Patients typically present with back pain, sensory disturbances, and weakness. It may also obstruct the cerebrospinal fluid (CSF) flow, leading to syringomyelia. In magnetic resonance (MR) studies, the "scalpel sign" is a classical finding, and it may also be accompanied by syringomyelia attributed to CSF flow. Definitive surgical resection is the mainstay of treatment. Case Description: A 31-year-old male presented with mild weakness in the right leg and diffuse lower extremity sensory changes. The MR showed the typical "scalpel sign" at the T7 level consistent with diagnosing a spinal arachnoid web. He underwent a T6-T8 laminotomy for lysis of the web and decompression of the thoracic cord. Postoperatively, his symptoms improved markedly. Conclusion: Surgical resection is the treatment of choice when an arachnoid web is documented on an MR and correlates with the patient's clinical symptoms/signs.

Necessity of fusion following decompression surgery in patients with single-level lumbar stenosis: study protocol for an open-label multicentre non-inferiority randomized controlled clinical trial.

BACKGROUND: The necessity of spinal segment fusion after decompression is one of the most controversial and unresolved issues in single-level lumbar spinal stenosis surgery. To date, only one trial carried out 15 years ago focused on this problem. The key purpose of the current trial is to compare the long-term clinical results of the two surgical methods (decompression vs. decompression and fusion) in patients with single-level lumbar stenosis. METHODS: This study is focused on the non-inferior clinical results of decompression compared with the standard fusion procedure. In the decompression group, the spinous process, the interspinous and supraspinous ligaments, part of the facet joints, and corresponding parts of the vertebral arch are to be preserved intact. In the fusion group, decompression is to be supplemented with transforaminal interbody fusion. Participants meeting the inclusion criteria will be randomly divided into two equal groups (1:1), depending on the surgical method. The final analysis will include 86 patients (43 per group). The primary endpoint is Oswestry Disability Index dynamics at the end of the 24-month follow-up compared to the baseline level. Secondary outcomes included those estimated using the SF-36 scale, EQ-5D-5L, and psychological scales. Additional parameters will include sagittal balance of the spine, fusion results, total cost of surgery, and hospital stay followed by two-year treatment. Follow-up examinations will be performed at 3, 6, 12, and 24 months DISCUSSION: Authors suggest that this study will improve the evidence for application of various surgical techniques for lumbar spine stenosis surgery and verify the existing protocol for surgical management. TRIAL REGISTRATION: ClinicalTrials.gov NCT05273879 . Registered on March 10, 2022.

Spinal Subarachnoid Hematoma After Cardiac Angiography in an Infant: A Case Report.

Spinal subarachnoid hematoma may result in sequelae such as bilateral lower extremity paralysis and vesicorectal disturbances. Although spinal subarachnoid hematoma is rare in infants, early intervention has been suggested to improve neurological prognosis. Therefore, clinicians are encouraged to make early diagnosis and surgical intervention. A 22-month-old boy was prescribed aspirin for a congenital heart disease. A routine cardiac angiography was performed under general anesthesia. Fever and oliguria developed on the next day, followed by flaccid paralysis of the lower limbs four days later. Five days later, he was diagnosed with spinal subarachnoid hematoma and associated spinal cord shock. Even after emergent posterior spinal decompression, hematoma removal, and rehabilitation, the patient remained with bladder rectal disturbance and flaccid paralysis of both lower limbs. Diagnosis and treatment of this case were delayed mainly because of his difficulty to complain of back pain and paralysis. The neurogenic bladder was one of the first neurological symptoms in our case, so it may be important to consider spinal cord involvement in infants with bladder compromise. Risk factors for spinal subarachnoid hematoma in infants are largely unknown. The patient had undergone a cardiac angiography the day before the onset of the symptoms, which may be related to subarachnoid hematoma. However, similar reports are scarce, with only one case of spinal subarachnoid hematoma reported in an adult following cardiac catheter ablation. Accumulation of evidence regarding risk factors for subarachnoid hematoma in infants is warranted.

Incidence and management of dural tears in full-endoscopic unilateral laminotomies for bilateral lumbar decompression.

PURPOSE: To report incidence of dural lacerations in lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) and to describe patient outcomes following a novel full-endoscopic bimanual durotomy repair. METHODS: Retrospective review of prospectively collected database including 5.5 years of single surgeon experience with LE-ULBD. Patients with no durotomy were compared with patients who experienced intraoperative durotomy, including demographics, ASA score, prior surgery, number of levels treated, procedure time, hospital length of stay (LOS), visual analogue scale, perioperative complications, revision surgeries, use of analgesics, and Oswestry Disability Index (ODI). RESULTS: In total, 13/174 patients (7.5%) undergoing LE-ULBD experienced intraoperative durotomy. No significant differences in demographic, clinical or operative variables were identified between the 2 groups. Sustaining a durotomy increased LOS (p = 0.0019); no differences in perioperative complications or rate of revision surgery were identified. There was no difference in minimally clinically important difference for ODI between groups (65.6% for no durotomy versus 55.6% for durotomy, p = 0.54). CONCLUSION: In this cohort, sustaining a durotomy increased LOS but, with accompanying intraoperative repair, did not significantly affect rate of complications, revision surgery or functional outcomes. Our method of bimanual endoscopic dural repair provides an effective approach for repair of dural lacerations in interlaminar ULBD cases.